CPT CODE 98960 AND 98961. 98962

CPT CODE AND Description

98960 - Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient - Average fee amount $25 - $35

98961 - Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients

98962 - Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients

Coding & Reimbursement:

Lactation consultations (98960) are separately reimbursed when filed by a licensed MD/DO or mid-level practitioners when the lactation consultation is the only service provided and performed by a certified lactation consultant under the general supervision of a licensed MD/DO or mid-level practitioner.

Lactation consultations (98960) are considered not separately reimbursed and part of the E & M service when it is provided at the same time as an E&M visit. 99201-99215, 99381-99397


lactation consultations will deny as not separately reimbursed for members (HCR and NHCR participants) when filed with a non-covered diagnosis not listed below.

If the service is provided by a Home Care Agency, the service is covered as part of the home care per diem.


The American Medical Association (AMA) has developed specific CPT codes intended for use by qualified health care professionals who are not Physicians to report their services. In some instances the intended use of a procedure or service is within the description of the code. For example CPT 98960 describes education and training for patient self-management by a qualified, nonphysician health care professional. In other instances the AMA has included parenthetical information in the CPT book as with CPT 96040 which says “These services are provided by trained genetic counselors and may include obtaining a structured family genetic history, pedigree construction, analysis for genetic risk assessment, and counseling of the patient and family.”

Conversely, the AMA instructs Physicians who provide genetic counseling and education, risk factor reduction intervention or medical nutrition therapy to use the appropriate evaluation and management codes to report these services. Existing evaluation and management codes include services such as taking a patient’s health and family history and counseling.

Therefore, in accordance with correct coding guidelines, Oxford will not reimburse nonphysician health care professional service codes (CPT 96040, 96150-96155, 97802-97804, 98960-98962 or HCPCS G0270-G0271) when reported by a Physician, because these codes are intended for use by nonphysician health care professionals. Physicians who provide genetic counseling, health and behavior assessment/intervention, medical nutrition therapy or education and training for patient self-management should report these services using evaluation and management codes. The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or  on-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.


There is a set of codes in the Current Procedural Terminology (CPT) codebook that describes education offered by non-physician providers. The code set which was added to CPT in 2006, codes98960-62, seems like an ideal fit for the types of services provided by technologists today; specifically education for positive airway pressure (PAP) management. The descriptor for code 98960 reads “Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient.”1  Codes 98961 and 98962 describe this service for two-four patients and five-eight patients respectively. While these codes may seem ideal, the term “standardized curriculum” limits the use of these codes.

Separately Reimbursed:

Lactation consultations (98960) are separately reimbursed when filed by a licensed MD/DO or mid-level practitioner when the lactation consultation is the only service provided and performed by a certified lactation consultant under the general supervision of a licensed MD/DO or midlevel practitioner.

Not Separately Reimbursed:

Lactation consultations (98960) are considered not separately reimbursed and part of the E & M service when it is provided at the same time as an E&M visit.

99201-99215
99381-99397

Lactation consultations will deny as not separately reimbursed for members ( HCR and NHCR participants) when filed with a non-covered diagnosis.

If the service is provided by a Homecare Agency, the service is covered as part of the homecare
Per Diem.


Effective for dates of services on or after Sept. 1, 2013, UnitedHealthcare will implement a new policy denying reimbursement of non-physician health care professional medicine services when reported by physicians. Supported by the AMA, physicians should report evaluation and management (E/M) services (CPT codes 99201-99499) instead of the following medicine codes which are intended for use by non-physician health care professionals:


• Education and training for patient selfmanagement (CPT codes 98960-98962)


Visit Limits: 

Reimbursement is allowed for 1 (one) lactation consult in a hospital outpatient setting (clinic) and 2 (two) in the physician office setting. This also applies to multiple deliveries.

CPT code 98960 should only be filed with an ICD-9-CM diagnosis code for a lactation disorder listed below:

98960 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

HMO, PPO, Individual Marketplace, Elite, Advantage 

Codes 98960, 98961, & 98962 are only covered for diabetic or asthmatic members for the purpose of diabetic or asthmatic education services. Codes G0108 & G0109 are only covered for diabetic members for the purpose of diabetic education. Members diagnosed with diabetes may receive up to 10 hours of initial training within a continuous 12-month period and up to 2 hours of follow-up training each year thereafter

Bundled Services and Supplies – professional

 For dates of service on or after July 1, 2015 we are updating Section 1 of the policy to include Current Procedural Terminology (CPT®) codes 98961 and 98962 (education and training for patient self-management by a qualified, nonphysician health care professional) as always bundled services. We consider these services to be part of the overall care management of the patient.

Florida Blue reimburses care coordination services within payment for specific programs or other procedures and does not reimburse care coordinate services separately reported with procedure codes 98961-98962, 98966-98968, 99487, 99489, G9001-G9012, S0257, S0280-S0281 or S0315.



• 98960 – Education Education and training training for patient patient self-management by a qualified, non-physician health care professional professional using a standardized standardized curriculum, face to face with the patient each 30 minutes


There is a set of codes in the Current Procedural Terminology (CPT) codebook that describes education offered by non-physician providers. The code set which was added to CPT in 2006, codes98960-62, seems like an ideal fit for the types of services provided by technologists today; specifically education for positive airway pressure (PAP) management. The descriptor for code 98960 reads “Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient.”1  Codes 98961 and 98962 describe this service for two-four patients and five-eight patients respectively. While these codes may seem ideal, the term “standardized curriculum” limits the use of these codes.



New Reimbursement Policy – Physicians Billing Non-physician Health Care Professional Medicine Services

Effective for dates of services on or after Sept. 1, 2013, UnitedHealthcare will implement a new policy denying reimbursement of non-physician health care professional medicine services when reported by physicians. Supported by the AMA, physicians should report evaluation and management (E/M) services (CPT codes 99201-99499) instead of the following medicine codes which are intended for use by non-physician health care professionals:

• Medical genetics and genetic counseling services (CPT code 96040)

• Health and behavior assessment/intervention (CPT codes 96150-96155)

• Medical nutrition therapy (CPT codes 97802- 97804, HCPCS codes G0270-G0271)

• Education and training for patient selfmanagement (CPT codes 98960-98962)


Education and Training for Patient Self-Management


If a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a nonphysician health care professional to provide education using a standardized curriculum for patients with that disease.

• The curriculum may be modified as necessary based on the patient's clinical needs or the patient or caregiver's cultural norms and health literacy.

• These services are used to teach the patient or caregiver how to effectively manage the illness(es) or condition(s) or delay disease comorbidity(ies) in conjunction with the professional health care team.

• They are reported based on the total face-to-face time (each 30 minutes) and the number of patients receiving the education and training.

• CPT code 98960 is reported for each 30 minutes of education and training provided to an individual patient; code 98961 is reported when they are provided to 2 to 4 patients; and code 98962 is reported when 5 to 8 patients receive them.

• For example, if a physician has a large number of asthmatic patients in the practice, the use of a standardized curriculum emphasizing the importance of peak flow monitoring, use of preventive medications, and avoidance of overuse of rescue medications should improve patient compliance and safety for this chronic illness.



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